1. If at first you don’t succeed… Karen Anderson Kim Stanley

2. Objectives  Describe the importance of a MD quality champion 2. Discuss the necessity of verifiable data 3. Describe methods to get to the core issues

3. One Smart IP Chick  The value of manual review  Just happens to notice what may be a trend…  Starts collecting data  Compares to national rates (NHSN)  Performs a literature search  Finding someone to take the time to listen  Harder than we thought

4. If at first you don’t succeed…  Do you give up?  NO WAY!!! ‘Giving up’ is not in the IP code  Collect more data for stronger case  Start peeling the

5.  Keep digging  Comparison to National Data  Apples to apples may not be what it appears  Search the literature  Understand what the literature shows (e.g. case definitions vary)  Ask colleagues what they are seeing  Go back to slide #2 – FIND SOMEONE important who is interested  Make your case with data

6. Our Story  Our surveillance included all NHSN breast procedures  96% of complex SSIs found in mastectomy patients  81% were immediate post reconstruction  95% in Tissue Expanders (TE)

7. Case Review  Patient Risk factors  Implant Placement  Chemotherapy  Radiation  Prophylactic or Therapeutic Mastectomy?  Acellular dermal matrix  Type of Mastectomy- nipple sparing or not?  Surgeon- Plast and Gen  Organisms  Skin Preparation  Preop CHG bathing  Preoperative/postop antibiotics  First outpatient saline fill date/technique  Early or late infections

8. Data Analysis Of statistical significance:  Nipple Sparing vs. Non-Nipple Sparing (p value= 0.0083)  Nipple Sparing with Subcutaneous placement vs. Submuscular placement (p value= 0.0395)

9. What We Did  Brought to light an issue that the surgeons (General and Plastic) were not acutely aware of  Opened the dialog between our departments:  Correct skin pens for use with CHG  Skin antisepsis  Preoperative antibiotics  Preoperative skin bathing  Skin antisepsis prior to accessing port for outpatient saline fill  No multidose vials of saline for outpatient clinics  Created a patient risk questionnaire to gather additional information on all patients undergoing TE

10. What We Did  Started a preoperative CHG bathing program for patients undergoing mastectomy with immediate reconstruction.  Preop and post op patient education created  We are still in the process of addressing the creation of evidence-based surgical guidelines and the outpatient technique for filling Tissue Expanders.  Still attend at least two Plastic Surgery Dept meetings a year to provide updates, receive feedback.

12. Lessons Learned  Do not give up  Find a respected champion and get them interested  Know your data inside out and backwards  You will be challenged by the surgeons  Do your homework- know what the literature shows  Understand how infection definitions may differ in published studies- they may not apply  Ask the surgeons for ideas/guidance  Make it obvious from the start that you are seeking to gain a deeper understanding of what the data “could” mean  Sometimes there is no smoking gun….and that’s ok!